title: Predictors of adverse outcomes in HIV-1-infected children receiving combination antiretroviral treatment: results from a DREAM cohort in sub-Saharan Africa.
abstract: BACKGROUND
  HIV-infected children have less access to combination antiretroviral therapy as compared with adults in resource-limited settings. Growth faltering, loss to follow-up (LTFU) and high mortality are frequently seen.
  
  
  METHODS
  A retrospective cohort study was performed with parameters extracted from the Drug Resource Enhancement against AIDS and Malnutrition database for HIV-infected, antiretroviral naïve children under 15 years presenting for care at 17 Drug Resource Enhancement against AIDS and Malnutrition centers in Mozambique, Malawi and Guinea between January 2005 to December 2008. Predictors of time-to-death, time-to-LTFU and persistence of malnutrition by Cox's regression and Kaplan-Meier were determined.
  
  
  RESULTS
  2215 children presented to care with 1343 (61%) being ≤ 5 years. At baseline, stunting and malnutrition occurred in 40% and 25%, respectively; 75% of 2149 children had CD4 cell percentages less than 20; median HIV RNA, log10 cp/mL, was 4.97 in 1927 patients. Over time 238 children died (10.7%; 2.7% person-years [PY]) 63 were LTFU (2.8%; 0.7% PY). By multivariate analysis, mortality was associated with virus load (hazards ratio: 1.19; confidence interval: 1.01-1.402, P = 0.038) and reduced weight-for-age Z scores (hazards ratio: 0.590; confidence interval: 0.53-0.66, P < 0.001). LTFU was associated with low weight-for-height Z scores (hazards ratio: 0.71; confidence interval: 0.51-0.97, P = 0.031). At 12 months after combination antiretroviral therapy, anthropometric parameters significantly improved in 1226 children (P < 0.001); virus load declined to <400 copies/mL in over 60%.
  
  
  CONCLUSIONS
  Despite advanced HIV disease, children initiating combination antiretroviral therapy had mortality rates of 2.7% p/PY with overall attrition rates of 11.7% p/100 PY, with significant reversal of negative anthropometric markers, and improvement of immunological and virological parameters in children with 12 months of follow-up.
authors.affiliation: From the *Department of Preventive Medicine, LUMSA University (Libera Università Maria SS. Assunta); †DREAM Program; ‡Department of Biomedicine and Prevention, Tor Vergata University, via Montpellier, Rome, Italy; §Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA; ¶Azienda Ospedaliedra Universitaria Senese, Siena; ‖Università Cattolica Sacro Cuore, Rome, Italy; and **DREAM Program Mozambique, Maputo, Mozambique.
authors.forename: Maria Cristina
authors.initials: MC
authors.lastname: Marazzi
authors.forename: Simona
authors.initials: S
authors.lastname: De Luca
authors.forename: Leonardo
authors.initials: L
authors.lastname: Palombi
authors.forename: Paola
authors.initials: P
authors.lastname: Scarcella
authors.forename: Fausto
authors.initials: F
authors.lastname: Ciccacci
authors.forename: Susanna
authors.initials: S
authors.lastname: Ceffa
authors.forename: Karin
authors.initials: K
authors.lastname: Nielsen-Saines
authors.forename: Andrea
authors.initials: A
authors.lastname: De Luca
authors.forename: Sandro
authors.initials: S
authors.lastname: Mancinelli
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Gennaro
authors.forename: Ines
authors.initials: I
authors.lastname: Zimba
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Liotta
authors.forename: Ersilia
authors.initials: E
authors.lastname: Buonomo
mesh_terms: D000293:Adolescent; D017954:Africa South of the Sahara / Q000453:epidemiology; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D001827:Body Height; D001835:Body Weight; D002648:Child; D002675:Child, Preschool; D004359:Drug Therapy, Combination; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology / Q000401:mortality; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D053208:Kaplan-Meier Estimate; D008297:Male; D044342:Malnutrition; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014376:Tuberculosis
chemical_list: D044966:Anti-Retroviral Agents